key: cord-1048728-1sm4efl3
authors: Morici, Nuccia; Puoti, Massimo; Zocchi, Maria Teresa; Brambilla, Carla; Mangiagalli, Andrea; Savonitto, Stefano
title: Home-based COVID 19 management: A consensus document from Italian general medical practitioners and hospital consultants in the Lombardy region (Italy)
date: 2020-12-02
journal: Eur J Intern Med
DOI: 10.1016/j.ejim.2020.11.025
sha: af076fe4442f3d7a6081f04b21b755715c567a39
doc_id: 1048728
cord_uid: 1sm4efl3

nan

The coronavirus disease 2019 (COVID-19) pandemic has infected more than 56,628,581 people causing 1,406,449 deaths worldwide, as of November 24, 2020. 1 Among the 17,131,853 active cases (November 24, 2020), 99% are reported as "mild", and 1% as "serious or critical", with the proportion between critical and mild cases remaining substantially unchanged throughout the outbreak.

This data shows the potential for an integrated hospital and home management of COVID-19 patients, thus avoiding saturation of hospital beds with patients with relatively mild symptoms.

These patients may not need oxygen therapy, and require surveillance of only a few parameters; yet, if systematically admitted to hospital, they may cause hospital overcrowding, spread the infection among health personnel, and reduce the potential of care for the sickest patients. 2 An integrated approach is critical in order to avoid a collapse of the health care system and social policies. Safe discharge of low-risk patients from the Emergency Room after initial diagnosis requires: a reliable, evidence-based and publicly endorsed definition of "low-risk"; plans and equipment for home surveillance, to be ready for admission of patients showing an unfavourable evolution; specific treatment, if any proven useful, to prevent complications; follow-up of possible organ damage to prevent any sequelae. 3 This approach can only be successful with a policy strategy based on an early involvement of general practitioners (GPs), a close bidirectional collaboration with the hospital system, and an official endorsement by the health care authorities. This synergy might serve as a template beyond the COVID-19 outbreak; it could serve for high transmission infectious disease and chronic disorders, improving antibiotic treatment at home (in the setting of national projects against antibiotics resistance), with positive effects on resource allocation, as it has been shown in the context of chronic obstructive pulmonary disease (COPD), diabetes, low-risk pulmonary embolism, 4 and heart failure. Literature review was updated on October, 2020. In order to set out to produce final recommendations, we used the GRADE (Grades of recommendation, assessment, development and evaluation) system, which provides a definition for the quality of evidence followed by a subsequent judgement about the strength of recommendations. 7, 8 All the available evidence is considered low to moderate, because mainly supported by the current clinical practice, whereas well designed studies are lacking. However, the recommendations provided in this document are considered strong, according to the GRADE"s binary classification, because of these key determinants: 1) the favourable balance between desirable and undesirable effect; 2) the limited uncertainty in values and preferences; 3) the more favourable effect in resource allocation compared to a more indiscriminate access to each emergency room; 4) their adoption and integration in official regional regulations by Lombardy policy makers. 9  Patients with symptoms suspected for SARS-CoV-2 infection should first contact their GPs.  The management model requires that upon receiving a patient call, the GP will register symptoms and report them on a specific datasheet on the Public Health Agency portal dedicated to the insertion of few essential data. The following symptoms will be collected, either via telephone call or through a dedicated web platform depending on local situation: body temperature; respiratory rate / min (if feasible); chest pain; cough; dyspnoea, at rest or exertional; anosmia or ageusia; headache/dizziness; myalgia; arthralgia; asthenia; vomit/diarrhea; loss of appetite; skin lesions, especially peripheral; conjunctivitis. Furthermore, oxygen saturation will be required (basal and exertional based on patient"s compliance) if the subject already possesses a pulse oximeter, otherwise this data will be obtained after delivering the instrument.

 Comorbidity will be quantified using a modified Elixhauser model, 10 which includes age, current cancer or having been treated for cancer in the previous year, known respiratory disease, obesity (BMI>30), ischemic heart disease or history of vasculopathy with treatments in the previous year, diabetes mellitus, eGFR< 60 ml/min or known chronic renal failure, current or previous HIV infection, coagulopathy, history of immune-depression or organ transplantation and falciform anaemia.

 Confirmed cases in the neighbourhood or household cluster will be considered risk factors too.

The risk stratification approach and the management scenarios are reported in Figure 1 . From a diagnostic standpoint a relevant tool is represented by lung ultrasound (LUS), that can be extensively used in this setting. LUS shows many advantages that made it increasingly used over the past few decades, especially in critical care and emergency setting. Compared to Chest X-Ray, LUS is easier to learn and to perform (5 minutes in most cases) and shows higher sensitivity and specificity. Moreover, it has shown a good correlation with CT scan. Unlike computerized tomography, LUS can be performed at bedside, minimizing the number of operators involved, and has no radiological hazard, which results of particular interest in pregnant and paediatric patients.

LUS images of COVID 19 pneumonia are similar to that of other interstitial viral pneumonia and ARDS of different origin. None of the LUS features seems to be COVID specific, even if a "light beam" appearance has been recently suggested as a typical sign of SARS-CoV-2 pneumonia. 11 However, during pandemic outbreaks, high clinical suspicion and high prevalence increase the pretest probability and LUS can contribute to early diagnosis of COVID 19 pneumonia. This potential benefit of LUS can be relevant for the correct management of infected patients in case RT-PCR swabs are not available or time for processing specimen is considered excessively long. 11 Due to its high negative predictive value LUS can be used to identify patients with low probability of pneumonia, thus furnishing a relevant aid in risk stratification and management. 11 A specific contribution of this project has been dedicated one-day workshops performed by emergency physicians for GP" students in the Milan Metropolitan Area. The first edition has been performed in October, 2020.

For patients with mild clinical illness and mild involvement at LUS, providing care at home may be considered, 2 as long as they can be followed up and cared for by family members. An assessment of the social context (general home conditions, caregivers) is an essential part of the initial patient evaluation, mostly by the GP. Patients and household members should be educated about personal hygiene measures that prevent the spread of infection to cohabitants at home. The patient and family members should be provided with ongoing support, adhering to established WHO recommendations. 9 Monitoring should continue for the duration of home care. In addition, sanitary assistance may be provided by the family physician and/or by nursing personnel of the health care system, by home visits and/or using simple tools of remote monitoring: appropriate and costeffective tools include transcutaneous oxygen saturimetry (delivered by the referral hospital for each city domain); body temperature; heart rate control. According to the published data only about 10 to 15% of such stratified and home-managed cases will subsequently require ER or hospital admission.

In conclusion, the present consensus document, resulting from a multispecialty collaboration and 

Fondazione Umberto Veronesi grant funds will contribute to cover costs for 4 days dedicated to ultrasound imaging training for 100 general practitioners (that will participate in the project).

Teachers will be representative physicians of ASST Grande Ospedale Metropolitano Niguarda, 

What Other Countries Can Learn From Italy During the COVID-19 Pandemic

Landi F for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19

Lankeit M; HoT-PE Investigators. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial

The clinical and integrated management of COPD. An official document of AIMAR (Interdisciplinary Association for Research in Lung Disease), AIPO (Italian Association of Hospital Penumologists)

SIMG (Italian Society of General Medicine)

Consensus methods for medical and health services research

What is the "quality of evidence" and why is it important to clinicians?

Going from evidence to recommendation

Deliberazione N° XI / 3876. Determinazioni per la gestione integrata ospedale-territorio per l"assistenza dei pazienti affetti da COVID 19 o sospetti

Comorbidity measures for use with administrative data

Is There a Role for Lung Ultrasound During the COVID-19 Pandemic?

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We further confirm that any aspect of the work covered in this manuscript that has involved either experimental animals or human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.